Preoperative Intra-Aortic Counterpulsation in Cardiac Surgery: Insights From a Retrospective Series of 588 Consecutive High-Risk Patients.

OBJECTIVE: To support a rational use of preoperative intra-aortic balloon pump (IABP) in cardiac surgery. DESIGN: Retrospective, observational study. SETTING: Single university hospital. PARTICIPANTS: The study included 588 (mean age 68.5 ± 9.6 yr) consecutive patients who received IABP before cardiac surgery from 1999 to 2016. INTERVENTIONS: Coronary surgery was performed in 573 (97.4%) cases. IABP indications were prophylaxis (n = 147), unstable angina (n = 239), and rapid worsening of hemodynamics (n = 202). Baseline characteristics of patients were analyzed with multivariable methods. Comparison of outcomes postsurgery between 74 patients undergoing IABP because of left main coronary artery disease (LMCAD) (stenosis ≥ 50%) and a new series of 1,360 patients experiencing LMCAD but who did not receive an IABP using propensity-score matching. MEASUREMENTS AND MAIN RESULTS: Throughout the study period, the rate of IABP use for prophylaxis and unstable angina increased (p = 0.0029) despite reduction in patient surgical risk (p = 0.0051). Early period of surgery (p = 0.032), rapid worsening of hemodynamics in the operating room (p = 0.0029), renal impairment (p < 0.0001), and ventilation before surgery (p = 0.0032) were predictors of in-hospital mortality. The cumulative rate of IABP-related complications was 6.8%. Current smoking (p = 0.025) and the use of a 9 Fr catheter (p = 0.0017) were predictors of IABP-related vascular complications. No difference was found regarding outcomes postsurgery for 43 pairs of IABP/non-IABP matched patients with LMCAD, even though preoperative IABP was associated with an increased use of bilateral internal thoracic artery grafting. CONCLUSIONS: Preoperative use of IABP in cardiac surgery was shown in this study to be safe, even for high-risk patients. LMCAD is not by itself a sufficient indication for prophylactic IABP.

Incidence and prognostic impact of bleeding and transfusion after coronary surgery in low-risk patients.

BACKGROUND: Excessive bleeding and blood transfusion are associated with adverse outcome after cardiac surgery, but their mechanistic effects are difficult to disentangle in patients with increased operative risk. This study aimed to evaluate the incidence and prognostic impact of bleeding and transfusion of blood products in low-risk patients undergoing coronary artery bypass grafting (CABG). STUDY DESIGN AND METHODS: Sixteen tertiary European centers of cardiac surgery contributed to the prospective European registry of CABG (E-CABG). The severity of bleeding was defined by the E-CABG bleeding severity classification and universal definition of perioperative bleeding (UDPB) classification. RESULTS: Of 1213 patients with EuroSCORE II of less than 2% (mean, 1.1 ± 0.4%), 18.5% suffered from mild bleeding (E-CABG bleeding Grade 1) and 3.4% experienced severe bleeding (E-CABG bleeding Grade 2-3). Similarly, 19.7% had UDPB Class 2 and 5.9% had UDPB Classes 3 and 4. Mild and severe bleeding defined by the E-CABG and UDPB classifications were associated with an increased risk of several adverse events as adjusted by multiple covariates. The risk of death, stroke, and acute kidney injury was particularly increased in patients with severe bleeding. CONCLUSION: Severe bleeding is rather uncommon in low-risk patients undergoing CABG, but it is associated with an increased risk of major adverse events. Prevention of excessive perioperative bleeding and patient blood management may improve the outcome of cardiac surgery also in low-risk patients.

Urgent Coronary Revascularization with Bilateral Internal Thoracic Artery Grafting: Is the Risk Justified?

Background The frequent need of immediate institution of cardiopulmonary bypass because of ischemia and increased risk of bleeding and longer duration of surgery limit the use of bilateral internal thoracic artery (BITA) grafting in urgency. Patients and Methods Of 4,525 consecutive patients with multivessel coronary artery disease who underwent isolated coronary bypass surgery at the authors' institution (1999-September 2015), 121 (2.7%) patients had an operation before the beginning of the next working day after decision to operate, which is the definition for emergency according to the European System for Cardiac Operative Risk Evaluation II. BITA and single internal thoracic artery (SITA) grafting were used in 52 and 46 of these patients, respectively; venous grafts alone were used in the remaining cases. BITA and SITA patients were compared as risk profiles, operative data, and outcomes. A propensity score (PS)-matched analysis was also performed. Results Between BITA and SITA patients, there was no significant difference as hospital mortality, both in the overall (3.8 vs. 6.5%; p = 0.66) and the PS-matched series (0 vs. 4.3%; p = 1). Among the postoperative complications, only bleeding (but not blood transfusion nor mediastinal re-exploration) was increased both in the overall (p = 0.037) and the PS-matched series of BITA patients (p = 0.092); duration of surgery was increased but not quite significantly (p = 0.12). Freedom from cardiac and cerebrovascular deaths, and major adverse cardiac and cerebrovascular events were higher in PS-matched BITA patients, even though not quite significantly (p = 0.11 for both). Conclusion BITA grafting may be performed even in urgency. With respect to SITA grafting, hospital mortality and postoperative complications other than bleeding are not increased; late outcomes seem to be better.

Glycated Hemoglobin and Risk of Sternal Wound Infection After Isolated Coronary Surgery.

BACKGROUND: Glycated hemoglobin (HbA1c) is a suspected risk factor for sternal wound infection (SWI) after CABG.Methods and Results:Data on preoperative HbA1c and SWI were available in 2,130 patients undergoing isolated CABG from the prospective E-CABG registry. SWI occurred in 114 (5.4%). Baseline HbA1c was significantly higher in patients with SWI (mean, 54±17 vs. 45±13 mmol/mol, P<0.0001). This difference was also observed in patients without a diagnosis of diabetes (P=0.027), in insulin-dependent diabetic (P=0.023) and non-insulin-dependent diabetic patients (P=0.034). In the overall series, HbA1c >70 mmol/mol (NGSP units, 8.6%) was associated with the highest risk of SWI (20.6% vs. 4.6%; adjusted OR, 5.01; 95% CI: 2.47-10.15). When dichotomized according to the cut-off 53 mmol/mol (NGSP units, 7.0%) as suggested both for diagnosis and optimal glycemic control of diabetes, HbA1c was associated with increased risk of SWI in the overall series (10.6% vs. 3.9%; adjusted OR, 2.09; 95% CI: 1.24-3.52), in diabetic patients (11.7% vs. 5.1%; adjusted OR, 2.69; 95% CI: 1.38-5.25), in patients undergoing elective surgery (9.9% vs. 2.7%; adjusted OR, 2.09; 95% CI: 1.24-3.52) and in patients with bilateral mammary artery grafts (13.7% vs. 4.8%; adjusted OR, 2.35; 95% CI: 1.17-4.69). CONCLUSIONS: Screening for HbA1c before CABG may identify untreated diabetic patients, as well as diabetic patients with suboptimal glycemic control, at high risk of SWI.

Predictors of immediate and long-term outcomes of coronary bypass surgery in patients with left ventricular dysfunction.

Despite encouraging improvements, outcomes of coronary artery bypass grafting (CABG) in the presence of left ventricular (LV) dysfunction remain poor. In the present study, the authors' experience on this subject was reviewed to establish the predictors of immediate and long-term results of surgery. Out of 4383 consecutive patients with multivessel coronary artery disease who underwent primary isolated CABG at the authors' institution from January 1999 throughout September 2014, 300 patients (mean age 66.1 ± 9.6 years) suffered preoperatively from LV dysfunction (defined as LV ejection fraction ≤35 %). The mean expected operative risk (EuroSCORE II) was 10.3 ± 13 %. Hospital deaths and perioperative complications were analyzed retrospectively. Outcomes were evaluated during a mean follow-up of 6.2 ± 4 years. None, one or both internal thoracic arteries (ITAs) were used in 6.3, 29 and 64.7 % of cases, respectively. There were 16 (5.3 %) hospital deaths. Prolonged invasive ventilation (17.7 %), acute kidney injury (14.7 %) and multiple blood transfusion (21.3 %) were the most frequent major postoperative complications. The 10-year non-parametric estimates of freedom from all-cause death, cardiac death, and major adverse cardiac and cerebrovascular events (MACCEs) were 47.8 [95 % confidence interval (CI) 44.1-51.5], 65.3 (95 % CI 61.4-69.2), and 42.3 % (95 % CI 38.3-46.3), respectively. Shared predictors of decreased late survival and MACCEs were old age (P < 0.04), chronic lung disease (P < 0.01), chronic dialysis (P < 0.0001) and extracardiac arteriopathy (P < 0.045). After adjustment for corresponding risk factors, freedom from cardiac death was higher when both ITAs were used but only for patients with significant increase of LV ejection fraction early after surgery (P = 0.04). In patients with LV dysfunction, CABG may be performed with acceptable hospital mortality and long-term survival. Late outcomes depend mainly on preoperative characteristics of the patients. The use of both ITAs for myocardial revascularization may give long-term survival benefits but only for patients whose LV function improves significantly early after surgery.

The Impact of Diabetes on Early Outcomes after Routine Bilateral Internal Thoracic Artery Grafting.

BACKGROUND: Increased risk of postoperative complications limits use of bilateral internal thoracic artery (BITA) grafting in diabetic patients. The authors' experience in routine BITA grafting was reviewed to investigate the impact of diabetes on early outcomes. METHODS: Among the 4508 consecutive patients with multivessel coronary artery disease who underwent isolated coronary bypass surgery from January 1999 throughout August 2015, skeletonised BITA grafts were used in 3228 (71.6%) patients, 972 diabetic and 2256 non-diabetic. After one-to-one propensity score (PS)-matched analysis, 819 pairs of diabetic/non-diabetic patients were compared for postoperative outcomes. The operative risk was calculated for each patient according to the European System for Cardiac Operative Risk Evaluation II (EuroSCORE II). RESULTS: Although diabetic had higher risk profiles than non-diabetic patients both in unmatched (EuroSCORE II: 5.3±7.3% vs. 3±4.2%, p<0.0001) and PS-matched series (EuroSCORE II: 5.1±7.1% vs. 3.6±4.3%, p<0.0001), there were no differences in hospital mortality (2.2% vs. 1.8%, p=0.52 and 2.1% vs. 2.3%, p=0.74, respectively). In PS-matched pairs, the use of adrenergic agonists (p=0.03), postoperative bleeding (p=0.0055) and deep incisional sternal wound infection (p=0.0018) were more frequent in diabetic patients who had a mean of longer hospital stays (p=0.023). CONCLUSIONS: Bilateral internal thoracic artery grafting may be routinely performed even in diabetic patients despite higher risk profiles. Increased postoperative complications prolong hospital stay but do not impact on early mortality.

Routine use of bilateral internal thoracic artery grafting in women: A risk factor analysis for poor outcomes.

BACKGROUND: Concerns about increased risk of postoperative complications, primarily deep sternal wound infection (DSWI), prevent liberal use of bilateral internal thoracic artery (BITA) grafting in women. Consequently, outcomes after routine BITA grafting remain largely unexplored in female gender. METHODS: Of 786 consecutive women with multivessel coronary disease who underwent isolated coronary bypass surgery at the authors' institution from 1999 throughout 2014, 477 (60.7%; mean age: 70±7.7years) had skeletonized BITA grafts; their risk profiles, operative data, hospital mortality and postoperative complications were reviewed retrospectively. Risk factor analysis for hospital death, DSWI and poor late outcomes were performed by means of multivariable models. RESULTS: There were 19 (4%) hospital deaths (mean EuroSCORE II: 5.2±6.1%); glomerular filtration rate<50ml/min was an independent risk factor (p=0.035). Prolonged invasive ventilation (11.3%), multiple blood transfusion (12.1%) and DSWI (10.7%) were most frequent major postoperative complications. Predictors of DSWI were body mass index >35kg/m2 (p=0.0094), diabetes (p=0.005), non-elective surgical priority (p=0.0087) and multiple blood transfusions (p=0.016). The mean follow-up was 6.8±4.5years. The non-parametric estimates of the 13-year freedom from cardiac and cerebrovascular deaths, major adverse cardiac and cerebrovascular events, and repeat myocardial revascularization were 76.1 [95% confidence interval (CI): 73.1-79.1], 59.5 (95% CI: 55.9-63.1) and 91.9% (95% CI: 90.1-93.7), respectively. Preoperative congestive heart failure (p=0.04) and left main coronary artery disease (p=0.0095) were predictors of major adverse cardiac and cerebrovascular events. CONCLUSIONS: BITA grafting could be performed routinely even in women. The increased rates of early postoperative complications do not prevent excellent late outcomes.

Flexible band versus rigid ring annuloplasty for functional tricuspid regurgitation: two different patterns of right heart reverse remodelling.

OBJECTIVES: Annuloplasty bands and rings are widely used to treat functional tricuspid regurgitation (TR). However, the question as to which is the ideal annuloplasty device remains open. Early and late outcomes of tricuspid valve annuloplasty with flexible band (B-TVA) or rigid ring (R-TVA) are compared in the present study. METHODS: Between 1999 and 2014, 462 consecutive patients (mean age, 69.2 ± 9.5 years) with grade ≥1+ functional TR (graded from 0 to 3+) underwent either B-TVA (n = 345; mean EuroSCORE II 9.2 ± 10.8%) or R-TVA (n = 117; mean EuroSCORE II 12 ± 13.4%) in addition to other cardiac procedures at the authors' institution. RESULTS: One-to-one propensity score-matched analysis resulted in 98 pairs with similar baseline characteristics and operative risk. Hospital mortality was 7.5% after B-TVA and 12% after R-TVA (P = 0.14). R-TVA was associated with higher rates of low cardiac output (10.1 vs 17.9%, P = 0.025) and transient complete atrioventricular block (10.3 vs 17.2%, P = 0.046). Among the matched pairs, there were no significant differences in hospital mortality (5.1 vs 9.2%, P = 0.27) and perioperative complications. Both in overall series and matched pairs, between B-TVA and R-TVA patients, there were no significant differences in freedom from all-cause death (P = 0.29 and 0.91), cardiac and cerebrovascular deaths (P = 0.63 and 0.87) and grade ≥2+ TR (P = 0.68 and 0.77). Right atrial and tricuspid valve reverse remodelling combined with right ventricular reverse remodelling occurred after R-TVA but not after B-TVA. CONCLUSIONS: B-TVA and R-TVA are equally effective in the treatment of functional TR. However, R-TVA causes over time a more complete right heart reverse remodelling.

Tricuspid Annuloplasty for Tricuspid Regurgitation Secondary to Left-Sided Heart Valve Disease: Immediate Outcomes and Risk Factors for Late Failure.

BACKGROUND: Tricuspid valve annuloplasty is the treatment of choice for tricuspid regurgitation (TR) secondary to left-sided heart valve disease (functional TR). METHODS: Between 1999 and 2014, 527 consecutive patients (mean age, 69.6 ± 9.5 years) with grade ≥ 1+ functional TR (graded from 0-3+) underwent tricuspid annuloplasty in addition to left-sided heart valve operations at the authors' institution. The operative risk (by the European System for Cardiac Operative Risk Evaluation II [EuroSCORE II]) was 10.4% ± 12.2%. Clinical data and echocardiographic studies were reviewed retrospectively during a mean follow-up of 5.2 ± 3.5 years. Risk factors for late repair failure were identified by multivariable analysis. RESULTS: Either suture (De Vega) or device annuloplasty was used in 14.8% and 85.2% of patients, respectively. Concomitant mitral or aortic valve surgery was performed in 92.6% and 35.9% of cases, respectively. There were 48 (9.1%) hospital deaths. The 10-year nonparametric estimates of freedom from all-cause death, cardiac and cerebrovascular deaths, and grade ≥ 2+ TR were 51.2% (95% confidence interval [CI], 47.8%-54.6%) 69.9% (95% CI, 67%-72.8%), and 77.8% (95% CI, 74.2%-81.4%), respectively. A left ventricular ejection fraction < 50% (P = 0.027), tricuspid annular diameter > 40 mm (P = 0.001), and use of De Vega annuloplasty (P = 0.019) were predictors of grade ≥ 2+ TR during the follow-up period. There was a strong link between grade ≥ 2+ TR and new left-sided valvular lesions (odds ratio, 5.3; P < 0.0001), primarily mitral regurgitation. CONCLUSIONS: After device annuloplasty and in the absence of preoperative left ventricular dysfunction and severe tricuspid annular dilatation, functional TR is generally controlled within grade 1+ during the follow-up period. Recurrent TR is associated with new left-sided valvular lesions.

Safety of Preoperative Use of Ticagrelor With or Without Aspirin Compared With Aspirin Alone in Patients With Acute Coronary Syndromes Undergoing Coronary Artery Bypass Grafting.

Importance: The optimal timing of discontinuation of ticagrelor before cardiac surgery is controversial. Objective: To evaluate the safety of preoperative use of ticagrelor with or without aspirin in patients with acute coronary syndromes (ACS) undergoing isolated coronary artery bypass grafting (CABG) compared with aspirin alone. Design, Setting, and Participants: This prospective, multicenter clinical trial was performed at 15 European centers of cardiac surgery. Participants were patients with ACS undergoing isolated CABG from the European Multicenter Study on Coronary Artery Bypass Grafting (E-CABG) registry between January and September 2015. Exposures: Before surgery, patients received ticagrelor with or without aspirin or aspirin alone. Main Outcomes and Measures: Severe bleeding as defined by the Universal Definition of Perioperative Bleeding (UDPB) and E-CABG bleeding classification criteria. A propensity score-matched analysis was performed to adjust for differences in baseline and operative covariates. Results: Of 2482 patients from the E-CABG registry, the study cohort included 786 (31.7%) consecutive patients with ACS (mean [SD] age, 67.1 [9.3] years; range, 32-88 years), and 132 (16.8%) were female. One-to-one propensity score matching provided 215 pairs, whose baseline and operative covariates had a standardized difference of less than 10%. Preoperative use of ticagrelor was associated with a similar risk of bleeding according to the UDPB and E-CABG bleeding classifications, but the incidence of platelet transfusion was higher in the ticagrelor group (13.5% [29 of 215] vs 6.0% [13 of 215]). Compared with those receiving aspirin alone, continuing ticagrelor up to the time of surgery or discontinuing its use less than 2 days before surgery was associated with a higher risk of platelet transfusion (22.7% [5 of 22] vs 6.4% [12 of 187]) and E-CABG bleeding grades 2 and 3 (18.2% [4 of 22] vs 5.9% [11 of 187]) and tended to have an increased risk of UDPB grades 3 and 4 (22.7% [5 of 22] vs 9.6% [18 of 187]). Among patients in whom antiplatelet drug use was discontinued at least 2 days before surgery, the incidence of platelet transfusion was 12.4% (24 of 193) in the ticagrelor group and 3.6% (1 of 28) in the aspirin-alone group. Conclusions and Relevance: In propensity score-matched analyses among patients with ACS undergoing CABG, the use of preoperative ticagrelor with or without aspirin compared with aspirin alone was associated with more platelet transfusion but similar degree of bleeding; in patients receiving ticagrelor 1 day before or up until surgery, there was an increased rate of severe bleeding.

Bleeding, transfusion and the risk of stroke after coronary surgery: A prospective cohort study of 2357 patients.

INTRODUCTION: This study was planned to investigate the impact of severe bleeding and blood transfusion on the development of stroke after coronary surgery. METHODS: This cohort study includes 2357 patients undergoing isolated CABG from the prospective European Coronary Artery Bypass Grafting (E-CABG) registry. Severity of bleeding was categorized according to the Universal Definition of Perioperative Bleeding (UDPB), E-CABG and PLATO definitions. RESULTS: Thirty patients (1.3%) suffered postoperative stroke. The amount of transfused red blood cell (RBC) (OR 1.10, 95%CI 1.03-1.18), preoperative use of unfractioned heparin (OR 4.49, 95%CI 1.91-10.60), emergency operation (OR 3.97, 95%CI 1.47-10.74), diseased ascending aorta (OR 4.62, 95%CI 1.37-15.65) and use of cardiopulmonary bypass (p = 0.043, OR 4.85, 95%CI 1.05-22.36) were independent predictors of postoperative stroke. Adjusted analysis showed that UDPB classes 3-4 (crude rate: 3.6% vs. 1.0%; adjusted OR 2.66, 95%CI 1.05-6.73), E-CABG bleeding grades 2-3 (crudes rate: 6.3% vs. 0.9%; adjusted OR 5.91, 95%CI 2.43-14.36), and PLATO life-threatening bleeding (crude rate: 2.5% vs. 0.6%, adjusted OR 3.70, 95%CI 1.59-8.64) were associated with an increased risk of stroke compared with no or moderate bleeding. CONCLUSIONS: Bleeding and blood transfusion are associated with an increased risk of stroke after CABG, which is highest in patients with severe bleeding.

Routine use of bilateral internal thoracic artery grafts for left-sided myocardial revascularization in insulin-dependent diabetic patients: early and long-term outcomes.

OBJECTIVES: Despite encouraging late outcomes, the use of bilateral internal thoracic artery (BITA) grafting for myocardial revascularization in diabetic patients remains controversial because of an increased risk of sternal complications. In the present study, early and long-term outcomes of the routine use of left-sided BITA grafting in insulin-dependent diabetic patients were reviewed retrospectively. METHODS: Among the 2701 consecutive patients who underwent isolated BITA grafting at the authors' institution from 1999 throughout 2012, 188 (mean age: 67 ± 9 years) were insulin-dependent diabetic patients. The mean expected operative risk, calculated according to the European System for Cardiac Operative Risk Evaluation II, was 11 ± 10.8%. RESULTS: There were 6 (3.2%) hospital deaths. Prolonged invasive ventilation (17.6%), multiple transfusion (16.5%), deep sternal wound infection (DSWI, 11.7%) and acute kidney injury (10.6%) were the most frequent major postoperative complications. Chronic lung disease (P = 0.08), low cardiac output (P = 0.039), multiple transfusion (P = 0.034) and mediastinal re-exploration (P = 0.071) were risk factors for DSWI. The mean follow-up was 5.7 ± 3.6 years. The 10-year non-parametric estimates of overall survival, freedom from cardiac and cerebrovascular death, and major adverse cardiac and cerebrovascular events were 57.7 [95% confidence interval (CI): 45.1-66.2], 83.6 (95% CI: 76.6-90.7) and 55.4% (95% CI: 44.7-66.1), respectively. Predictors of decreased late survival were old age (P = 0.013), chronic lung disease (P = 0.004), renal impairment (P = 0.009) and left ventricular dysfunction (P = 0.035). CONCLUSIONS: Left-sided BITA grafting may be performed routinely even in insulin-dependent diabetic patients. The increased rates of postoperative complications do not prevent low early mortality and good long-term outcomes.